- Email: [email protected]
General Surgery Morning Report: A Competency-Based Conference that Enhances Patient Care and Resident Education
2006 APDS SPRING MEETING
General Surgery Morning Report: A Competency-Based Conference that Enhances Patient Care and Resident Education Brendon M. Stiles, MD, T. Brett Reece, MD, Traci L. Hedrick, MD , Robert A. Garwood, MD, Michael G. Hughes, MD , Joseph J. Dubose, MD, Reid B. Adams, MD , Bruce D. Schirmer, MD , Hilary A. Sanfey, MD , and Robert G. Sawyer, MD Department of Surgery, University of Virginia Health System, Charlottesville, Virginia PURPOSE: After adopting a night float system, the residency
program at the University of Virginia Health System Department of Surgery initiated a daily morning report (MR). The conference was originated to sign out new admissions and consults from the previous day to the services that would assume care. Although initially oriented toward transfer of patient information, MR is also hypothesized to serve as a competencybased resident education tool. METHODS: An anonymous survey was distributed to on-
service residents (n ⫽ 25). Questions were asked on a 5-point Likert scale. Respondents also ranked the weekly conferences, including MR, in terms of educational benefit derived.
RESULTS: Most residents agreed that MR is an efficient
method to sign-out patient care [84% stongly agree (SA) or agree (A)] and that it provides an excellent educational experience (88% SA or A). They agreed that it is presented in an evidence-based format (88% SA or A). Regarding the core competencies, residents all asserted that MR addresses “patient care” (100% SA or A) and “medical knowledge” (100% SA or A). Most agreed that it addresses “professionalism” (60% SA or A), “interpersonal skills and communication” (76% SA or A), and “practice-based learning and improvement” (92% SA or A). The 4 most important components identified with respect to continuing to improve both patient care and resident education were the presence of the on-call attending, a review of relevant radiology, provision of follow-up on select cases, and critical review of the literature. On average, MR was seen as the most educational conference, with 52% of residents ranking it first. CONCLUSIONS: Although MR is ubiquitous in most pri-
mary care residency programs, such a conference has not typically been held on surgical services. The MR was developed at the University of Virginia Health System Department of SurCorrespondence: Inquiries to Dr. Brendon Stiles, University of Virginia Health System, Department of Surgery, 1221 Lee Street, Charlottesville, VA 22908; e-mail: [email protected]
gery as a necessity for patient sign-out. As this conference has continued to evolve, it has become an excellent tool for resident education. It now serves the purpose of enhancing patient care and medical education and of providing evidence of learning and assessment of the general competencies. The MR provides an example for program directors of how to tailor existing resident work sessions or conferences to meet Accreditation Council for Graduate Medical Education (ACGME) competency requirements. (Curr Surg 63:385-390. © 2006 by the Association of Program Directors in Surgery.)
INTRODUCTION Over the past several years, numerous challenges have occurred to the classic paradigm of surgical education. Change has been driven by many factors, including the economic needs of hospital systems and individual residents, workforce issues, resident lifestyle expectations, and a continued move toward specialization within general surgery.1-3 Perhaps the most important engines for change have been the implementation of the Accreditation Council for Graduate Medical Education’s (ACGME’s) system for competencybased teaching and assessment and the adoption of the ACGME’s resident duty-hour guidelines. In July 2001, the ACGME mandated U.S. residencies to implement a curriculum and evaluation strategy based on 6 general competencies as follows: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice.4 The challenge to surgical training programs has been to integrate this competency-based system at a time of decreased resident availability secondary to work-hour restrictions. The ACGME timeline calls for programs to provide evidence of assessment of the competencies, beginning in July 2006. It is obviously attractive to use existing conferences and learning modules to demonstrate implementation and evaluation of these competencies. The 80-hour-work week and its associated working environment guidelines went into effect in July 2003. Since the enact-
CURRENT SURGERY • © 2006 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/06/$30.00 doi:10.1016/j.cursur.2006.06.005
385
ment of these regulations, a great deal of effort has been put into determining what effect they have had on graduate medical education (GME) in surgery and surgical subspecialties. Many institutions, including the University of Virginia Health System, adopted “Night Float” or similar cross-cover systems to meet the ACGME work-hour restrictions. The Night Float System presents several challenges of its own. Residents working in a Night Float System may have less attending interaction and face-to-face teaching and may not be available for didactic sessions that take place during the day.5 Methods to ensure the educational benefit of such a system have been described.6 Apart from the educational challenges, the Night Float System has been criticized for disrupting continuity of care and creating a “shift-work mentality.” In such a system, it is critical to develop a reliable “sign-out” system to transfer pertinent clinical information.7 At the University of Virginia, a daily morning report (MR) was initiated to discuss and turn over new admissions and consults from the previous night to the services that would assume care. This conference was initially oriented strictly toward the transfer of patient information. However, it soon became apparent that, within MR, several “teachable moments” existed. This opportunity was seized to develop MR as a teaching conference. For this study, MR is hypothesized as an effective resident education tool that can be used to provide evidence of learning and assessment of the ACGME’s general competencies.
METHODS The current chief resident class made it a priority to use MR as a teaching conference, in addition to its existing role as a signout conference. They wanted to ensure that MR was an efficient method for turnover of patient care, but that it also provided excellent educational opportunities for the residents and medical students. MR was conducted in an evidence-based rather than a “personal experience” format. MR occurs daily, from 6:30 to 7:00 AM, including weekends. It is attended by medical students (15-20), residents (20-25), and a small number of attendings, typically including the post-call attending. MR takes place in a comfortable 80-seat auditorium with modern audio-visual capabilities (large projection screen, PowerPoint format, Internet/Medline access, PACS radiology access). The Night Float consult resident presents admissions and consults from the previous night, whereas the post-call senior resident leads the case discussion and highlights pertinent teaching points. The 2 residents identify cases worthy of more detailed discussion before MR and typically focus on those cases, often with evidence-based reviews of the literature. Pertinent laboratory and radiological findings are shown, and questions regarding patient presentation and management are asked in a levelappropriate manner, beginning with the medical students and working up through the resident hierarchy. Follow-up is provided on cases from previous presentations, particularly when the diagnosis has not yet been made or when further studies have been obtained. 386
A log was kept of all cases over a 1-month period to determine case distribution. To determine whether the established MR goals were being met, an anonymous survey was distributed to on-service residents (n ⫽ 25) halfway through the clinical year. Whether the respondents were junior or senior residents was recorded. Questions were asked regarding the value of MR, how it addresses the core competencies, and how it could be improved with regard to patient care and resident education. Answers on a 5-point Likert scale included “strongly agree” (SA), “agree” (A), “don’t know or neutral” (N), “disagree” (D), and “strongly disagree” (SD). Respondents were also asked to rank the weekly teaching conferences, including MR, morbidity and mortality (M&M), grand rounds, and specialty conferences, in terms of educational benefit derived. Open-ended questions were also written to attain further resident input. In terms of defining the competencies, no standard definitions were given with this survey. However, residents review the ACGME’s competencies each month during the internal evaluation process. This process uses several examples within each competency to generate an understanding of the overall purpose of each. Two lectures were conducted regarding the implementation and scope of the competencies to the current group of residents before this survey. Data were collected and analyzed.
RESULTS An average of 7 cases per day were discussed, predominantly related to general surgery and trauma (Fig. 1). A wide range of topics were discussed, however, including transplant, cardiothoracic, vascular, and pediatric surgery cases. All residents (100%) completed the anonymous survey, which was evenly split between junior (52%) and senior residents (48%). Most residents agreed (Fig. 2) that MR is an efficient method to sign-out patient care (84% SA or A) and that it provides an excellent educational experience (88% SA or A). They agreed that it is presented in an evidence-based format (88% SA or A). Overall, 80% of residents agreed that MR takes place in an atmosphere of collegiality and respect. No resident strongly disagreed with any of those statements. Only 1 person strongly
FIGURE 1. Average consult cases per day discussed at MR.
CURRENT SURGERY • Volume 63/Number 6 • November/December 2006
FIGURE 2. General opinion of MR. No residents strongly disagreed with any of the assertions.
agreed that MR exists primarily to meet service requirements, whereas 60% of respondents were either neutral or disagreed. A series of questions was asked that was designed to elucidate the critical components of MR with respect to both patient care and resident education. With regard to maintaining or improving patient care, the most important elements identified were the presence of the on-call attending (100% SA or A), review of the relevant radiology (96% SA or A), provision of follow-up on select cases (96% SA or A), increased attending participation in general (84% SA or A), chief-resident-led discussion (80% SA or A), and designating clear responsibility for assuming patient care (80% SA or A). The responses given were similar regarding resident education (Table 1). An emphasis on a critical review of the literature and on using case-based questions was more pronounced in terms of educational benefit. Residents believed that the following components of MR are critical to education: the presence of the attending on-call (100% SA or A); follow-up on select cases (100% SA or A), review of relevant radiology (96% SA or A), review of pertinent literature (92% SA or A), case-based questions (88% SA or A), increased attending participation (84% SA or A), and chief-resident-led discussion (84% SA or A). Interestingly, although residents desired more attending participation, they strongly favored a chief-resident-led discussion as opposed to an attending-led discussion (32% SA or A, 52% D). Residents were also predominantly against the discussion being led by only 1 person (28% SA or A, 52% D or SD). Overall, 76% of residents agreed that discussing surgical subspecialty consults contributed to the educational merit of the conference.
FIGURE 3. Residents were asked to agree or disagree that the structure, content, and environment of MR address the ACGME’s general competencies.
Regarding the ACGME’s general competencies (Fig. 3), residents all asserted that MR addresses “patient care” (100% SA or A) and “medical knowledge” (100% SA or A). Most agreed that it addresses “practice-based learning and improvement” (92% SA or A), “interpersonal skills and communication” (76% SA or A), and “professionalism” (60% SA or A). No resident disagreed (D or SD) that MR addressed “patient care,” “medical knowledge,” or “practice-based learning and improvement.” Only 12% disagreed that MR addresses “interpersonal skills and communication,” whereas 20% disagreed that it addresses “professionalism.” Residents also ranked MR and other conferences in terms of educational benefit derived. They ranked MR, M&M, specialty conferences, and grand rounds from the most educational to the least, respectively (Fig. 4). Although the difference between MR and M&M was not statistically significant (p ⫽ 0.24), MR demonstrated a significant educational advantage when compared with specialty conferences and with grand rounds (p ⬍ 0.001). Overall, 60% of residents gave written responses to the openended question, “How would you improve morning report?” Of these responses, 40% specifically mentioned increased attending participation or discussion. Comments included “man-
TABLE 1. Key Components
Percent SA or A
Presence of on-call attending Follow-up on select cases Review of relevant radiology Critical review of literature Case-based questions Attending participation Chief resident led discussion
100% 100% 96% 92% 88% 84% 84%
FIGURE 4. Residents were asked to rank conferences in terms of educational benefit. The MR was the highest-rated conference.
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datory attending on-call presence,” “clear outline of attending plan for follow-up,” and “perhaps a short attending presentation on controversial cases.” A second recurring theme was the importance of avoiding “tangents.” Residents wrote, “discussion topics must be carefully selected,” “more direction, less off-on-a-tangent discussion,” and “more focus on the cases presented.” Other points mentioned included “more explanation of treatment choices,” “brief summary of each case at the end of discussion,” “encourage enthusiasm,” “standardize presentations,” and “better in a smaller, more conversational environment.”
DISCUSSION Although MR is ubiquitous in most primary care residency programs, such a conference has not typically been held on surgical services and is not described in the literature. A comprehensive review of MR by Amin et al cites no surgical papers.8 Additionally, a Medline search combining “surgery or surgical residency” and “morning report or residents’ report” yielded only 3 citations, none of which described a specific conference (performed February 1, 2006). Therefore, this study is believed to be the first documented in the literature describing a Department of Surgery MR, although undoubtedly such conferences exist elsewhere. Historically, MR has served many purposes that fall under 5 basic subheadings: education, evaluation of residents and services, reporting of adverse events, non-medical issues, and social interactions.8 MR was developed at the University of Virginia Health System as a necessity for patient signout after implementing a Night Float System in response to the 80-hour-work week.6 Despite this initial intent, only 1 person in this survey strongly agreed that MR exists primarily to meet service requirements, suggesting that MR has come to be seen primarily as a teaching conference. The MR case presentation format sets the stage for contextual learning. In contrast to standard curriculum lectures, in which learning is generally passive, MR provides an opportunity for active learning. Gagne9,10 has described an arrangement of 9 specific instructional events to achieve optimum learning outcomes. These consist of learner and teacher activities. The first 3e events (gaining attention, informing the learner of the objectives, and stimulating recall) collectively prepare the learner for instruction. The next 2 events (presenting the information and providing learner guidance) are the core of the teaching/learning process and are designed to help the resident and student understand the topic. The final 4 events (eliciting performance, providing feedback, assessing performance, and enhancing transfer) give the resident and student the opportunity to check and enhance learning, correct misunderstanding, and think about how knowledge can be applied in other contexts. Through open-ended questions and dialogue during MR, the group discusses diagnostic and management dilemmas, and participants are often asked, “What would you do next?” The incorporation of key and relevant clinical, laboratory, and radiological findings encourages abstraction and conceptualiza388
tion, which are both important phases of experiential education.11 Reciprocal peer teaching enhances cooperative learning and improves communication skills,12 which places the emphasis on actively pursuing a diagnosis and on group clinical problem solving. Senior residents provide formative feedback to assist the more junior residents in applying their knowledge base to the problem at hand. Such a system of active learning has been thought to engage learners with the instructional content and with each other, to improve conceptual understanding, and to facilitate skills for life-long learning.13 Reilly and Lemon14 have described a 4-phase MR to foster active learning. This surgical MR can be compared with this model (Table 2). Residents who participate in active learning sessions consider themselves, and are observed to be, more engaged with the session content.15 In this study, a benefit to conferences based on such active learning clearly existed. MR and M&M far exceeded the more traditionally didactic specialty conferences and grand rounds in terms of educational benefit derived. That MR was the highest rated conference is not surprising given its format and the learning needs of today’s generation-X residents and students: a learning environment in which everyone is a teacher; that offers several sources of information and encourages continued learning; that presents continuous challenges that contribute to overall knowledge; and that creates an open line of communication that promotes a mutual exchange of information.16 As MR has continued to evolve at this institution, it has become an excellent tool for resident and medical student education by meeting these needs. Importantly, MR was also used to provide evidence of both learning and assessment of the ACGME’s general competencies. Programs must demonstrate accumulation of such data beginning in July 2006, according to the ACGME’s timeline, which is part of an overall move away from process- and structureoriented education to competency-based teaching and assessment. The focus will be on “how well do those taught actually perform?”17 MR is believed to be a very suitable educational vehicle for such a system (Table 3). As this MR is resident-led as
TABLE 2.
Phase 1
Phase 2 Phase 3 Phase 4
Reilly & Lemon Model (1 hour)
University of Virginia (30 minutes)
Search report of literature based on previous day’s case. Review of admissions log. Detailed case presentations.
List admissions and consults.
Formulating the search for the next day.
Detailed discussion of “interesting” cases. Review of clinical/ laboratory/radiological findings. Patient handover, review of teaching points with literature search. Follow-up on previous day’s cases.
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TABLE 3. Patient Care Patient-focused discussions Review information pertaining to patients: physical examination, laboratory values, radiological studies Make evidence-based and experience-based evaluation and critique of clinical decisions Allows for development and modification of treatment plans Allows input/clinical experience from multiple physicians Medical Knowledge Direct application of knowledge to patient care Residents and students asked to demonstrate an analytical approach to clinical scenarios Promotes an evidence-based approach Encourages review of unanswered/disputed questions and promotes self-directed learning Practice-Based Learning Real patient scenarios Assimilate and appraise evidence from literature relating to patients Allows for discussion of study design and statistical methods Dependent on information technology to manage resources Interpersonal and Communication Skills Emphasizes the importance of concise and descriptive presentations Highlights relationships among resident–resident, resident– consultant, and resident–student Provides an opportunity to see how peers interact with others Demonstrates methods to both give and receive constructive criticism Professionalism Holds residents accountable for their decision making Highlights resident interactions with consulting physicians Reinforces sensitive issues in a diverse patient population Encourages residents to establish working relationship with each other and with students Systems-Based Practice Demonstrates how surgical practice affects other health-care professionals Facilitates discussions of cost-effective strategies and of resource allocation Addresses system complexities in an open forum
opposed to the attending-led format often favored by internal medicine programs, it is uniquely well suited to assess resident performance in the clinical environment. This format provides a venue to address specific competencies and provides ample opportunity to evaluate residents at all levels as they work their way through the case-based presentations. Junior residents are typically called on to demonstrate basic medical knowledge and to demonstrate proficiency in patient care. Senior residents emphasize systems-based practice and are ultimately responsible for patient care decision making. Interpersonal skills and communication are critical to both parties in terms of describing the patient presentation, asking level-appropriate questions, and developing and critiquing personal knowledge bases and patient care plans. This forum also provides ample opportunity to evaluate professionalism and to refine one’s skill set within that competency, in terms of interacting with consultants as well as the residents and students in attendance at MR. Although the
use of MR to evaluate residents’ clinical skills, attitude, and quality of care has been previously described,18 this report is believed to be the first to describe the use of MR in the context of the ACGME’s general competencies. Another positive aspect of MR is that it emphasizes the “resident as teacher” role. Studies have shown that residents can contribute substantially to the education and clinical training of each other and of medical students.19-21 The knowledge and professional competency of residents correlates positively with their perceived teaching abilities.19 MR could be a unique platform for residents to improve their teaching skills and confidence. Apker et al22 noted that MR involves a highly public display of professional identity expectations. Case presentations turn into self-presentations as residents develop skills and strategies to look their best in front of an evaluative audience. The purposefully participative nature of MR necessarily involves residents in discussion so that faculty can evaluate their case knowledge, mastery of medical information, and clinical skills. The goal is for residents to solve a case, gather relevant information, challenge theories and decisions, and defend their own perspective. By interacting with peers and role models, residents and students learn the culture of medicine and how to develop their professional identities within it.22 In conclusion, many challenges have occurred to the way in which surgical residents and students are traditionally trained. Training must occur in a shorter work week, and residents must demonstrate proficiency in specific competencies. A departmental MR was instituted to ensure patient continuity of care within this new system. Serendipitously, MR has become an integral educational tool for the surgery residents and students at the University of Virginia Health System. It is an opportunity for residents to exercise and improve their knowledge, leadership, presentation, and problem-solving skills. MR not only serves the dual purposes of enhancing patient care and medical education, but it also provides evidence of learning and assessment of the general competencies. This conference provides an example for programs of how to tailor existing resident work sessions or conferences to meet ACGME competency requirements.
REFERENCES 1. Brennan MF, Debas HT. Surgical education in the
United States: portents for change. Ann Surg. 2004;240: 565-572. 2. Debas HT, Bass BL, Brennan MF, Flynn TC, Folse JR,
Freischlag JA, et al. American Surgical Association Blue Ribbon Committee report on surgical education: 2004. Ann Surg. 2005;241:1-8. 3. Richardson JD. Training of general surgical residents:
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what model is appropriate? Am J Surg. 2006;191:296300. 389
4. Leach DC. The ACGME competencies: substance or
13. Bonwell CC, Sutherland TE. Using Active Learning
form? Accreditation Council for Graduate Medical Education. J Am Coll Surg. 2001;192:396-398.
in College Classes: A Range of Options for Faculty. San Francisco, CA: Jossey-Bass; 1996.
5. Darosa DA, Bell RH Jr, Dunnington GL. Residency pro-
gram models, implications, and evaluation: results of a think tank consortium on resident work hours. Surgery. 2003;133:13-23. 6. Lefrak S, Miller S, Schirmer B, Sanfey H. The night float
system: ensuring educational benefit. Am J Surg. 2005; 189:639-642. 7. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH.
Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121: 866-872. 8. Amin Z, Guajardo J, Wisniewski W, Bordage G,
Tekian A, Niederman LG. Morning report: focus and methods over the past three decades. Acad Med. 2000; 75:S1-S5. 9. Gredler MG. Learning and Instruction. Theory into
Practice. Columbus, OH: Pearson Merrill Prentice Hall; 2005. 10. Dent L, Harden R. A Practical Guide for Medical Teachers.
Oxford, UK: Elsevier; 2005.
14. Reilly B, Lemon M. Evidence-based morning report: a
popular new format in a large teaching hospital. Am J Med. 1997;103:419-426. 15. Haidet P, Morgan RO, O’Malley K, Moran BJ, Richards
BF. A controlled trial of active versus passive learning strategies in a large group setting. Adv Health Sci Educ Theory Pract. 2004;9:15-27. 16. Caudron S. Can Generation Xers be trained? Training
Develop. 1997;51:20-24. 17. Brasel KJ, Bragg D, Simpson DE, Weigelt JA. Meeting
the Accreditation Council for Graduate Medical Education competencies using established residency training program assessment tools. Am J Surg. 2004;188:9-12. 18. Parrino TA, Villanueva AG. The principles and practice
of morning report. JAMA. 1986;256:730-733. 19. Busari JO, Scherpbier AJ. Why residents should teach:
a literature review. J Postgrad Med. 2004;50:205-210. 20. Busari JO, Prince KJ, Scherpbier AJ, Van Der Vleuten
CP, Essed GG. How residents perceive their teaching role in the clinical setting: a qualitative study. Med Teach. 2002;24:57-61. 21. Whittaker LD Jr, Estes NC, Ash J, Meyer LE. The value
11. Svinicki MD, Dixon NM. The Kolb Model modified to
classroom teaching. College Teaching. 2006;35:141-146.
of resident teaching to improve student perceptions of surgery clerkships and surgical career choices. Am J Surg. 2006;191:320-324.
12. Krych AJ, March CN, Bryan RE, Peake BJ, Pawlina W,
22. Apker J, Eggly S. Communicating professional identity in
Carmichael SW. Reciprocal peer teaching: students teaching students in the gross anatomy laboratory. Clin Anat. 2005;18:296-301.
medical socialization: considering the ideological discourse of morning report. Qual Health Res. 2004;14:411429.
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CURRENT SURGERY • Volume 63/Number 6 • November/December 2006
General Surgery Morning Report: A Competency-Based Conference that Enhances Patient Care and Resident Education Brendon M. Stiles, MD, T. Brett Reece, MD, Traci L. Hedrick, MD , Robert A. Garwood, MD, Michael G. Hughes, MD , Joseph J. Dubose, MD, Reid B. Adams, MD , Bruce D. Schirmer, MD , Hilary A. Sanfey, MD , and Robert G. Sawyer, MD Department of Surgery, University of Virginia Health System, Charlottesville, Virginia PURPOSE: After adopting a night float system, the residency
program at the University of Virginia Health System Department of Surgery initiated a daily morning report (MR). The conference was originated to sign out new admissions and consults from the previous day to the services that would assume care. Although initially oriented toward transfer of patient information, MR is also hypothesized to serve as a competencybased resident education tool. METHODS: An anonymous survey was distributed to on-
service residents (n ⫽ 25). Questions were asked on a 5-point Likert scale. Respondents also ranked the weekly conferences, including MR, in terms of educational benefit derived.
RESULTS: Most residents agreed that MR is an efficient
method to sign-out patient care [84% stongly agree (SA) or agree (A)] and that it provides an excellent educational experience (88% SA or A). They agreed that it is presented in an evidence-based format (88% SA or A). Regarding the core competencies, residents all asserted that MR addresses “patient care” (100% SA or A) and “medical knowledge” (100% SA or A). Most agreed that it addresses “professionalism” (60% SA or A), “interpersonal skills and communication” (76% SA or A), and “practice-based learning and improvement” (92% SA or A). The 4 most important components identified with respect to continuing to improve both patient care and resident education were the presence of the on-call attending, a review of relevant radiology, provision of follow-up on select cases, and critical review of the literature. On average, MR was seen as the most educational conference, with 52% of residents ranking it first. CONCLUSIONS: Although MR is ubiquitous in most pri-
mary care residency programs, such a conference has not typically been held on surgical services. The MR was developed at the University of Virginia Health System Department of SurCorrespondence: Inquiries to Dr. Brendon Stiles, University of Virginia Health System, Department of Surgery, 1221 Lee Street, Charlottesville, VA 22908; e-mail: [email protected]
gery as a necessity for patient sign-out. As this conference has continued to evolve, it has become an excellent tool for resident education. It now serves the purpose of enhancing patient care and medical education and of providing evidence of learning and assessment of the general competencies. The MR provides an example for program directors of how to tailor existing resident work sessions or conferences to meet Accreditation Council for Graduate Medical Education (ACGME) competency requirements. (Curr Surg 63:385-390. © 2006 by the Association of Program Directors in Surgery.)
INTRODUCTION Over the past several years, numerous challenges have occurred to the classic paradigm of surgical education. Change has been driven by many factors, including the economic needs of hospital systems and individual residents, workforce issues, resident lifestyle expectations, and a continued move toward specialization within general surgery.1-3 Perhaps the most important engines for change have been the implementation of the Accreditation Council for Graduate Medical Education’s (ACGME’s) system for competencybased teaching and assessment and the adoption of the ACGME’s resident duty-hour guidelines. In July 2001, the ACGME mandated U.S. residencies to implement a curriculum and evaluation strategy based on 6 general competencies as follows: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice.4 The challenge to surgical training programs has been to integrate this competency-based system at a time of decreased resident availability secondary to work-hour restrictions. The ACGME timeline calls for programs to provide evidence of assessment of the competencies, beginning in July 2006. It is obviously attractive to use existing conferences and learning modules to demonstrate implementation and evaluation of these competencies. The 80-hour-work week and its associated working environment guidelines went into effect in July 2003. Since the enact-
CURRENT SURGERY • © 2006 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/06/$30.00 doi:10.1016/j.cursur.2006.06.005
385
ment of these regulations, a great deal of effort has been put into determining what effect they have had on graduate medical education (GME) in surgery and surgical subspecialties. Many institutions, including the University of Virginia Health System, adopted “Night Float” or similar cross-cover systems to meet the ACGME work-hour restrictions. The Night Float System presents several challenges of its own. Residents working in a Night Float System may have less attending interaction and face-to-face teaching and may not be available for didactic sessions that take place during the day.5 Methods to ensure the educational benefit of such a system have been described.6 Apart from the educational challenges, the Night Float System has been criticized for disrupting continuity of care and creating a “shift-work mentality.” In such a system, it is critical to develop a reliable “sign-out” system to transfer pertinent clinical information.7 At the University of Virginia, a daily morning report (MR) was initiated to discuss and turn over new admissions and consults from the previous night to the services that would assume care. This conference was initially oriented strictly toward the transfer of patient information. However, it soon became apparent that, within MR, several “teachable moments” existed. This opportunity was seized to develop MR as a teaching conference. For this study, MR is hypothesized as an effective resident education tool that can be used to provide evidence of learning and assessment of the ACGME’s general competencies.
METHODS The current chief resident class made it a priority to use MR as a teaching conference, in addition to its existing role as a signout conference. They wanted to ensure that MR was an efficient method for turnover of patient care, but that it also provided excellent educational opportunities for the residents and medical students. MR was conducted in an evidence-based rather than a “personal experience” format. MR occurs daily, from 6:30 to 7:00 AM, including weekends. It is attended by medical students (15-20), residents (20-25), and a small number of attendings, typically including the post-call attending. MR takes place in a comfortable 80-seat auditorium with modern audio-visual capabilities (large projection screen, PowerPoint format, Internet/Medline access, PACS radiology access). The Night Float consult resident presents admissions and consults from the previous night, whereas the post-call senior resident leads the case discussion and highlights pertinent teaching points. The 2 residents identify cases worthy of more detailed discussion before MR and typically focus on those cases, often with evidence-based reviews of the literature. Pertinent laboratory and radiological findings are shown, and questions regarding patient presentation and management are asked in a levelappropriate manner, beginning with the medical students and working up through the resident hierarchy. Follow-up is provided on cases from previous presentations, particularly when the diagnosis has not yet been made or when further studies have been obtained. 386
A log was kept of all cases over a 1-month period to determine case distribution. To determine whether the established MR goals were being met, an anonymous survey was distributed to on-service residents (n ⫽ 25) halfway through the clinical year. Whether the respondents were junior or senior residents was recorded. Questions were asked regarding the value of MR, how it addresses the core competencies, and how it could be improved with regard to patient care and resident education. Answers on a 5-point Likert scale included “strongly agree” (SA), “agree” (A), “don’t know or neutral” (N), “disagree” (D), and “strongly disagree” (SD). Respondents were also asked to rank the weekly teaching conferences, including MR, morbidity and mortality (M&M), grand rounds, and specialty conferences, in terms of educational benefit derived. Open-ended questions were also written to attain further resident input. In terms of defining the competencies, no standard definitions were given with this survey. However, residents review the ACGME’s competencies each month during the internal evaluation process. This process uses several examples within each competency to generate an understanding of the overall purpose of each. Two lectures were conducted regarding the implementation and scope of the competencies to the current group of residents before this survey. Data were collected and analyzed.
RESULTS An average of 7 cases per day were discussed, predominantly related to general surgery and trauma (Fig. 1). A wide range of topics were discussed, however, including transplant, cardiothoracic, vascular, and pediatric surgery cases. All residents (100%) completed the anonymous survey, which was evenly split between junior (52%) and senior residents (48%). Most residents agreed (Fig. 2) that MR is an efficient method to sign-out patient care (84% SA or A) and that it provides an excellent educational experience (88% SA or A). They agreed that it is presented in an evidence-based format (88% SA or A). Overall, 80% of residents agreed that MR takes place in an atmosphere of collegiality and respect. No resident strongly disagreed with any of those statements. Only 1 person strongly
FIGURE 1. Average consult cases per day discussed at MR.
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FIGURE 2. General opinion of MR. No residents strongly disagreed with any of the assertions.
agreed that MR exists primarily to meet service requirements, whereas 60% of respondents were either neutral or disagreed. A series of questions was asked that was designed to elucidate the critical components of MR with respect to both patient care and resident education. With regard to maintaining or improving patient care, the most important elements identified were the presence of the on-call attending (100% SA or A), review of the relevant radiology (96% SA or A), provision of follow-up on select cases (96% SA or A), increased attending participation in general (84% SA or A), chief-resident-led discussion (80% SA or A), and designating clear responsibility for assuming patient care (80% SA or A). The responses given were similar regarding resident education (Table 1). An emphasis on a critical review of the literature and on using case-based questions was more pronounced in terms of educational benefit. Residents believed that the following components of MR are critical to education: the presence of the attending on-call (100% SA or A); follow-up on select cases (100% SA or A), review of relevant radiology (96% SA or A), review of pertinent literature (92% SA or A), case-based questions (88% SA or A), increased attending participation (84% SA or A), and chief-resident-led discussion (84% SA or A). Interestingly, although residents desired more attending participation, they strongly favored a chief-resident-led discussion as opposed to an attending-led discussion (32% SA or A, 52% D). Residents were also predominantly against the discussion being led by only 1 person (28% SA or A, 52% D or SD). Overall, 76% of residents agreed that discussing surgical subspecialty consults contributed to the educational merit of the conference.
FIGURE 3. Residents were asked to agree or disagree that the structure, content, and environment of MR address the ACGME’s general competencies.
Regarding the ACGME’s general competencies (Fig. 3), residents all asserted that MR addresses “patient care” (100% SA or A) and “medical knowledge” (100% SA or A). Most agreed that it addresses “practice-based learning and improvement” (92% SA or A), “interpersonal skills and communication” (76% SA or A), and “professionalism” (60% SA or A). No resident disagreed (D or SD) that MR addressed “patient care,” “medical knowledge,” or “practice-based learning and improvement.” Only 12% disagreed that MR addresses “interpersonal skills and communication,” whereas 20% disagreed that it addresses “professionalism.” Residents also ranked MR and other conferences in terms of educational benefit derived. They ranked MR, M&M, specialty conferences, and grand rounds from the most educational to the least, respectively (Fig. 4). Although the difference between MR and M&M was not statistically significant (p ⫽ 0.24), MR demonstrated a significant educational advantage when compared with specialty conferences and with grand rounds (p ⬍ 0.001). Overall, 60% of residents gave written responses to the openended question, “How would you improve morning report?” Of these responses, 40% specifically mentioned increased attending participation or discussion. Comments included “man-
TABLE 1. Key Components
Percent SA or A
Presence of on-call attending Follow-up on select cases Review of relevant radiology Critical review of literature Case-based questions Attending participation Chief resident led discussion
100% 100% 96% 92% 88% 84% 84%
FIGURE 4. Residents were asked to rank conferences in terms of educational benefit. The MR was the highest-rated conference.
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datory attending on-call presence,” “clear outline of attending plan for follow-up,” and “perhaps a short attending presentation on controversial cases.” A second recurring theme was the importance of avoiding “tangents.” Residents wrote, “discussion topics must be carefully selected,” “more direction, less off-on-a-tangent discussion,” and “more focus on the cases presented.” Other points mentioned included “more explanation of treatment choices,” “brief summary of each case at the end of discussion,” “encourage enthusiasm,” “standardize presentations,” and “better in a smaller, more conversational environment.”
DISCUSSION Although MR is ubiquitous in most primary care residency programs, such a conference has not typically been held on surgical services and is not described in the literature. A comprehensive review of MR by Amin et al cites no surgical papers.8 Additionally, a Medline search combining “surgery or surgical residency” and “morning report or residents’ report” yielded only 3 citations, none of which described a specific conference (performed February 1, 2006). Therefore, this study is believed to be the first documented in the literature describing a Department of Surgery MR, although undoubtedly such conferences exist elsewhere. Historically, MR has served many purposes that fall under 5 basic subheadings: education, evaluation of residents and services, reporting of adverse events, non-medical issues, and social interactions.8 MR was developed at the University of Virginia Health System as a necessity for patient signout after implementing a Night Float System in response to the 80-hour-work week.6 Despite this initial intent, only 1 person in this survey strongly agreed that MR exists primarily to meet service requirements, suggesting that MR has come to be seen primarily as a teaching conference. The MR case presentation format sets the stage for contextual learning. In contrast to standard curriculum lectures, in which learning is generally passive, MR provides an opportunity for active learning. Gagne9,10 has described an arrangement of 9 specific instructional events to achieve optimum learning outcomes. These consist of learner and teacher activities. The first 3e events (gaining attention, informing the learner of the objectives, and stimulating recall) collectively prepare the learner for instruction. The next 2 events (presenting the information and providing learner guidance) are the core of the teaching/learning process and are designed to help the resident and student understand the topic. The final 4 events (eliciting performance, providing feedback, assessing performance, and enhancing transfer) give the resident and student the opportunity to check and enhance learning, correct misunderstanding, and think about how knowledge can be applied in other contexts. Through open-ended questions and dialogue during MR, the group discusses diagnostic and management dilemmas, and participants are often asked, “What would you do next?” The incorporation of key and relevant clinical, laboratory, and radiological findings encourages abstraction and conceptualiza388
tion, which are both important phases of experiential education.11 Reciprocal peer teaching enhances cooperative learning and improves communication skills,12 which places the emphasis on actively pursuing a diagnosis and on group clinical problem solving. Senior residents provide formative feedback to assist the more junior residents in applying their knowledge base to the problem at hand. Such a system of active learning has been thought to engage learners with the instructional content and with each other, to improve conceptual understanding, and to facilitate skills for life-long learning.13 Reilly and Lemon14 have described a 4-phase MR to foster active learning. This surgical MR can be compared with this model (Table 2). Residents who participate in active learning sessions consider themselves, and are observed to be, more engaged with the session content.15 In this study, a benefit to conferences based on such active learning clearly existed. MR and M&M far exceeded the more traditionally didactic specialty conferences and grand rounds in terms of educational benefit derived. That MR was the highest rated conference is not surprising given its format and the learning needs of today’s generation-X residents and students: a learning environment in which everyone is a teacher; that offers several sources of information and encourages continued learning; that presents continuous challenges that contribute to overall knowledge; and that creates an open line of communication that promotes a mutual exchange of information.16 As MR has continued to evolve at this institution, it has become an excellent tool for resident and medical student education by meeting these needs. Importantly, MR was also used to provide evidence of both learning and assessment of the ACGME’s general competencies. Programs must demonstrate accumulation of such data beginning in July 2006, according to the ACGME’s timeline, which is part of an overall move away from process- and structureoriented education to competency-based teaching and assessment. The focus will be on “how well do those taught actually perform?”17 MR is believed to be a very suitable educational vehicle for such a system (Table 3). As this MR is resident-led as
TABLE 2.
Phase 1
Phase 2 Phase 3 Phase 4
Reilly & Lemon Model (1 hour)
University of Virginia (30 minutes)
Search report of literature based on previous day’s case. Review of admissions log. Detailed case presentations.
List admissions and consults.
Formulating the search for the next day.
Detailed discussion of “interesting” cases. Review of clinical/ laboratory/radiological findings. Patient handover, review of teaching points with literature search. Follow-up on previous day’s cases.
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TABLE 3. Patient Care Patient-focused discussions Review information pertaining to patients: physical examination, laboratory values, radiological studies Make evidence-based and experience-based evaluation and critique of clinical decisions Allows for development and modification of treatment plans Allows input/clinical experience from multiple physicians Medical Knowledge Direct application of knowledge to patient care Residents and students asked to demonstrate an analytical approach to clinical scenarios Promotes an evidence-based approach Encourages review of unanswered/disputed questions and promotes self-directed learning Practice-Based Learning Real patient scenarios Assimilate and appraise evidence from literature relating to patients Allows for discussion of study design and statistical methods Dependent on information technology to manage resources Interpersonal and Communication Skills Emphasizes the importance of concise and descriptive presentations Highlights relationships among resident–resident, resident– consultant, and resident–student Provides an opportunity to see how peers interact with others Demonstrates methods to both give and receive constructive criticism Professionalism Holds residents accountable for their decision making Highlights resident interactions with consulting physicians Reinforces sensitive issues in a diverse patient population Encourages residents to establish working relationship with each other and with students Systems-Based Practice Demonstrates how surgical practice affects other health-care professionals Facilitates discussions of cost-effective strategies and of resource allocation Addresses system complexities in an open forum
opposed to the attending-led format often favored by internal medicine programs, it is uniquely well suited to assess resident performance in the clinical environment. This format provides a venue to address specific competencies and provides ample opportunity to evaluate residents at all levels as they work their way through the case-based presentations. Junior residents are typically called on to demonstrate basic medical knowledge and to demonstrate proficiency in patient care. Senior residents emphasize systems-based practice and are ultimately responsible for patient care decision making. Interpersonal skills and communication are critical to both parties in terms of describing the patient presentation, asking level-appropriate questions, and developing and critiquing personal knowledge bases and patient care plans. This forum also provides ample opportunity to evaluate professionalism and to refine one’s skill set within that competency, in terms of interacting with consultants as well as the residents and students in attendance at MR. Although the
use of MR to evaluate residents’ clinical skills, attitude, and quality of care has been previously described,18 this report is believed to be the first to describe the use of MR in the context of the ACGME’s general competencies. Another positive aspect of MR is that it emphasizes the “resident as teacher” role. Studies have shown that residents can contribute substantially to the education and clinical training of each other and of medical students.19-21 The knowledge and professional competency of residents correlates positively with their perceived teaching abilities.19 MR could be a unique platform for residents to improve their teaching skills and confidence. Apker et al22 noted that MR involves a highly public display of professional identity expectations. Case presentations turn into self-presentations as residents develop skills and strategies to look their best in front of an evaluative audience. The purposefully participative nature of MR necessarily involves residents in discussion so that faculty can evaluate their case knowledge, mastery of medical information, and clinical skills. The goal is for residents to solve a case, gather relevant information, challenge theories and decisions, and defend their own perspective. By interacting with peers and role models, residents and students learn the culture of medicine and how to develop their professional identities within it.22 In conclusion, many challenges have occurred to the way in which surgical residents and students are traditionally trained. Training must occur in a shorter work week, and residents must demonstrate proficiency in specific competencies. A departmental MR was instituted to ensure patient continuity of care within this new system. Serendipitously, MR has become an integral educational tool for the surgery residents and students at the University of Virginia Health System. It is an opportunity for residents to exercise and improve their knowledge, leadership, presentation, and problem-solving skills. MR not only serves the dual purposes of enhancing patient care and medical education, but it also provides evidence of learning and assessment of the general competencies. This conference provides an example for programs of how to tailor existing resident work sessions or conferences to meet ACGME competency requirements.
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